Реформа фінансування системи охорони здоров’я в Україні: прогрес та майбутні напрями: огляд звіту

У 2015 р. український уряд ініціював трансформаційну реформу системи охорони здоров’я, метою якої було поліпшення показників здоров’я населення та забезпечення фінансового захисту від надмірних витрат на охорону здоров’я «з кишені» пацієнтів. Реформа повинна була впроваджуватися шляхом модернізації та інтеграції системи надання послуг, запровадження змін до механізмів оплати надавачам медичних послуг, які б стимулювали ефективність, а також шляхом покращення якості медичних послуг. Кульмінацією реформи став новий закон про фінансування системи охорони здоров’я—Закон України «Про державні фінансові гарантії медичного обслуговування населення» 2017 р.,—яким було запроваджено гарантований пакет медичних послуг під назвою Програма медичних гарантій (ПМГ) і створено Національну службу здоров’я України (НСЗУ) в ролі стратегічного закупівельника послуг для цієї програми. Передбачалося, що з часом ПМГ буде розширюватися і зрештою охопить всі види медичної допомоги, а фінансування охорони здоров’я перейде від кошто рисного фінансування до методів фінансування, орієнтованих на результат, що забезпечить краще узгодження надаваних медичних послуг з потребами пацієнтів.

Реформа фінансування системи охорони здоров’я в Україні: прогрес та майбутні напрями

У 2015 р. український уряд ініціював трансформаційну реформу системи охорони здоров’я, метою якої було поліпшення показників здоров’я населення та забезпечення фінансового захисту від надмірних витрат на охорону здоров’я «з кишені» пацієнтів. Реформа повинна була впроваджуватися шляхом модернізації та інтеграції системи надання послуг, запровадження змін до механізмів оплати надавачам медичних послуг, які б стимулювали ефективність, а також шляхом покращення якості медичних послуг. Кульмінацією реформи став новий закон про фінансування системи охорони здоров’я—Закон України «Про державні фінансові гарантії медичного обслуговування населення» 2017 р.,—яким було запроваджено гарантований пакет медичних послуг під назвою Програма медичних гарантій (ПМГ) і створено Національну службу здоров’я України (НСЗУ) в ролі стратегічного закупівельника послуг для цієї програми. Передбачалося, що з часом ПМГ буде розширюватися і зрештою охопить всі види медичної допомоги, а фінансування охорони здоров’я перейде від кошто рисного фінансування до методів фінансування, орієнтованих на результат, що забезпечить краще узгодження надаваних медичних послуг з потребами пацієнтів.

The 2017 reform to improve financial sustainability of national health insurance in Estonia: Analysis and first lessons on broadening the revenue base.

In 2017, the Estonian government addressed the longstanding challenge of financial sustainability of the health system by expanding its revenue base. As a relatively low-spending country on health, Estonia relies predominantly on payroll contributions from the working population, which exposes the system to economic shocks and population ageing. In an effort to reduce these vulnerabilities, Estonia will gradually introduce a government transfer on behalf of pensioners, although long-term sustainability of the health system could still prove challenging as the overall health spending as a percentage of GDP is not expected to substantially increase. Estonia has rolled out the reform according to plan, but it has led to debate about the need to achieve universal population coverage (currently at about 95%). Moreover, the Estonian experience also holds important lessons for other countries looking to reform their health system. For example, policymakers should recognize that reforms require extensive preparation using consistent messaging over a long period of time, also to prevent prioritising short term and popular fixes over structural reforms. Additionally, collaboration between the health and financial ministries throughout the reform increases the buy-in for the reform and likelihood of adoption. Furthermore, health professionals play a significant role in advocacy, and seeking support from this group can smooth the path towards health system reform.

Can people afford to pay for health care? New evidence on financial protection in Kyrgyzstan

This review examines the extent to which people living in Kyrgyzstan experience financial hardship when using health services, it is structured as follows. Section 2 sets out the analytical approach and sources of data used to measure financial protection. Section 3 provides a brief overview of health coverage and access to health care. Sections 4 and 5 present the results of the statistical analysis of household data, with a focus on out-of-pocket payments in Section 4 and financial protection in Section 5. Section 6 provides a discussion of the results of the financial protection analysis and identifies factors that strengthen and undermine financial protection: those that affect people’s capacity to pay for health care, and health system factors. Section 7 highlights implications for policy and draws attention to areas that require further analysis. Annex 1 provides information on household budget surveys; Annex 2 the methods used; Annex 3 regional and global financial protection indicators; Annex 4 a glossary of terms; and Annex 5 the KIHBS.This review is part of a series of country-based studies generating newevidence on financial protection in European health systems.

Expansion of health insurance in Moldova and associated improvements in access and reductions in direct payments.

BACKGROUND: Moldova is the poorest country in Europe. Economic constraints mean that Moldova faces challenges in protecting individuals from excessive costs, improving population health and securing health system sustainability. The Moldovan government has introduced a state benefit package and expanded health insurance coverage to reduce the burden of health care costs for citizens. This study examines the effects of expanded health insurance by examining factors associated with health insurance coverage, likelihood of incurring out-of-pocket (OOP) payments for medicines or services, and the likelihood of forgoing health care when unwell. METHODS: Using publically available databases and the annual Moldova Household Budgetary Survey, we examine trends in health system financing, health care utilization, health insurance coverage, and costs incurred by individuals for the years 2006-2012. We perform logistic regression to assess the likelihood of having health insurance, incurring a cost for health care, and forgoing health care when ill, controlling for socio-economic and demographic covariates. FINDINGS: Private expenditure accounted for 55.5% of total health expenditures in 2012. 83.2% of private health expenditures is OOP payments-especially for medicines. Healthcare utilization is in line with EU averages of 6.93 outpatient visits per person. Being uninsured is associated with groups of those aged 25-49 years, the self-employed, unpaid family workers, and the unemployed, although we find lower likelihood of being uninsured for some of these groups over time. Over time, the likelihood of OOP for medicines increased (odds ratio OR = 1.422 in 2012 compared to 2006), but fell for health care services (OR = 0.873 in 2012 compared to 2006). No insurance and being older and male, was associated with increased likelihood of forgoing health care when sick, but we found the likelihood of forgoing health care to be increasing over time (OR = 1.295 in 2012 compared to 2009). CONCLUSIONS: Moldova has achieved improvements in health insurance coverage with reductions in OOP for services, which are modest but are eroded by increasing likelihood of OOP for medicines. Insurance coverage was an important determinant for health care costs incurred by patients and patients forgoing health care. Improvements notwithstanding, there is an unfinished agenda of attaining universal health coverage in Moldova to protect individuals from health care costs.

Shifting chronic disease management from hospitals to primary care in Estonian health system: analysis of national panel data.

BACKGROUND: Following independence from the Soviet Union in 1991, Estonia introduced a national insurance system, consolidated the number of health care providers, and introduced family medicine centred primary health care (PHC) to strengthen the health system. METHODS: Using routinely collected health billing records for 2005-2012, we examine health system utilisation for seven ambulatory care sensitive conditions (ACSCs) (asthma, chronic obstructive pulmonary disease [COPD], depression, Type 2 diabetes, heart failure, hypertension, and ischemic heart disease [IHD]), and by patient characteristics (gender, age, and number of co-morbidities). The data set contained 552 822 individuals. We use patient level data to test the significance of trends, and employ multivariate regression analysis to evaluate the probability of inpatient admission while controlling for patient characteristics, health system supply-side variables, and PHC use. FINDINGS: Over the study period, utilisation of PHC increased, whilst inpatient admissions fell. Service mix in PHC changed with increases in phone, email, nurse, and follow-up (vs initial) consultations. Healthcare utilisation for diabetes, depression, IHD and hypertension shifted to PHC, whilst for COPD, heart failure and asthma utilisation in outpatient and inpatient settings increased. Multivariate regression indicates higher probability of inpatient admission for males, older patient and especially those with multimorbidity, but protective effect for PHC, with significantly lower hospital admission for those utilising PHC services. INTERPRETATION: Our findings suggest health system reforms in Estonia have influenced the shift of ACSCs from secondary to primary care, with PHC having a protective effect in reducing hospital admissions.

Progress in increasing affordability of medicines for non-communicable diseases since the introduction of mandatory health insurance in the Republic of Moldova.

BACKGROUND: To assess progress in improving affordability of medicines since the introduction of mandatory health insurance in the Republic of Moldova. METHOD: Using data from national health insurance, we estimate affordability of partially reimbursed medicines for the treatment of non-communicable diseases, and analyse which factors contributed to changes in affordability. RESULTS: Affordability of subsidized medicines improved over time. In 2013, it took a median of 0.84 days of income for the lowest income quintile (ranging from 0 to 3.32 days) to purchase 1 month of treatment for cardiovascular conditions in comparison to 1.85 days in 2006. This improvement however was mainly driven by higher incomes rather than deeper coverage through the reimbursement list. CONCLUSION: If mandatory health insurance is to improve affordability of medicines for the Moldovan population, more funds need to be (re-)allocated to enable higher percentage coverage of essential medicines and efficiencies need to be generated within the health system. These should include a budget reallocation between secondary and primary care, strengthening primary care to manage chronic conditions and raise population awareness, implementation of evidence-based selection and quality use of medicines in both outpatient and inpatient settings, improving monitoring and regulation of prices and the supply chain; and alignment of national treatment guidelines and clinical practice with international best practices and evidence-based medicine.

Barriers to universal health coverage in Republic of Moldova: a policy analysis of formal and informal out-of-pocket payments.

BACKGROUND: Universal Health Coverage seeks to assure that everyone can obtain the health services they need without financial hardship. Countries which rely heavily on out-of-pocket (OOP) payments, including informal payments (IP), to finance total health expenditures are not likely to achieve universal coverage. The Republic of Moldova is committed to promoting universal coverage, reducing inequities, and expanding financial protection. To achieve these goals, the country must reduce the proportion of total health expenditures paid by households. This study documents the extent of OOP payments and IP in Moldova, analyses trends over time, and identifies factors which may be driving these payments. METHODS: The study includes analysis of household budget survey data and previous research and policy documents. The team also conducted a review of administrative law intended to control OOP payments and IPs. Focus groups, interviews, and a policy dialogue with key stakeholders were held to validate and discuss findings. RESULTS: OOP payments account for 45% of total health expenditures. Sixteen percent of outpatients and 30% of inpatients reporting that they made OOP payments when seeking care at a health facility in 2012, more than two-thirds of whom also reported paying for medicines at a pharmacy. Among those who paid anything, 36% of outpatients and 82% of inpatients reported paying informally, with the proportion increasing over time for inpatient care. Although many patients consider these payments to be gifts, around one-third of IPs appear to be forced, posing a threat to health care access. Patients perceive that payments are driven by the limited list of reimbursable medicines, a desire to receive better treatment, and fear or extortion. Providers suggested irrational prescribing and ordering of tests as drivers. Providers may believe that IPs are gifts and do not cause harm for patients and the health system in general. CONCLUSIONS: Efforts to expand financial protection should focus on reducing household spending on medicines and hospital-based IPs. Reforms should consider ways to reduce medicine prices and promote rational use, strengthen administrative controls, and increase incentives for quality health care provision.

Strategic purchasing reform in Estonia: Reducing inequalities in access while improving care concentration and quality.

As of 2014, the Estonian Health Insurance Fund has adopted new purchasing procedures and criteria, which it now has started to implement in specialist care. Main changes include (1) redefined access criteria based on population need rather than historical supply, which aim to achieve more equal access of providers and specialties; (2) stricter definition and use of optimal workload criteria to increase the concentration of specialist care (3) better consideration of patient movement; and (4) an increased emphasis on quality to foster quality improvement. The new criteria were first used in the contract cycle that started in 2014 and resulted in fewer contracted providers for a similar volume of care compared to the previous contract cycle. This implies that provision of specialized care has become concentrated at fewer providers. It is too early to draw firm conclusions on the impact on care quality or on actors, but the process has sparked debate on the role of selective contracting and the role of public and private providers in Estonian health care. Lastly, the Estonian experience may hold important lessons for other countries looking to overcome inequalities in access while concentrating care and improving care quality.

An in-depth analysis of pharmaceutical regulation in the Republic of Moldova.

OBJECTIVE: Regulation of the pharmaceutical system is a crucial, yet often neglected, component in ensuring access to safe and effective medicines. The aim of this study was to provide an in-depth analysis of the existing pharmaceutical regulation, including recent changes, in the Republic of Moldova. METHODS: Data from field work conducted by the World Health Organization (WHO) together with a review of policy documents and quantitative secondary data analysis was used to achieve this aim. RESULTS: This analysis identified several ways in which pharmaceutical regulation affects availability of quality medicines in the Republic of Moldova. These include lack of full implementation bioequivalence requirements for generics registration, incomplete implementation of good manufacturing practices and no implementation of good distribution practices, use of quality control instead of quality assurance as a method to ensure quality of medicines, frequent change of power within the Medicines and Medical Devices Agency (MMDA) leading to lack of long-term strategy and plans, conflict of interest between the different functions of the MMDA, the lack of sufficient funding for the MMDA to conduct its activities and to invest in continuous training of its staff (particularly inspectors) and very weak post-marketing control. Notably, several improvements have been recently introduced, including a roadmap for change for the MMDA, the introduction of good manufacturing practices and the drafting of a quality manual for the Agency. CONCLUSION: Based on these findings the authors propose a set of priority actions to address existing gaps and draw lessons learned from other countries.

Better noncommunicable disease outcomes: challenges and opportunities for health systems: Republic of Moldova: country assessment

Like many countries, the Republic of Moldova faces a growing NCD burden. This report examines the challenges and opportunities faced in the Republic of Moldova in order to accelerate improvement in NCD outcomes. In recent years, the Government of the Republic of Moldova has implemented a number of important reforms that have increased efficiency and equity in resource allocation, and have provided incentives to improve service delivery, including for NCDs. Challenges include further scale up and implementation of new initiatives in the area of NCD risk factor management. Major gains can be made through relatively low-cost public health and primary health care interventions. These include, among others, strengthening tobacco, alcohol, and dietary polices and their implementation, improving detection and treatment of risk factors for cardiovascular disease, including hypertension and hyperlipidaemia, strengthening clinical protocols, and improving rational prescribing practice. This report examines in depth the health system challenges and opportunities for improved prevention and control of NCDs and concludes with policy recommendations for the consideration of policy makers in the Republic of Moldova.

Better noncommunicable disease outcomes challenges and opportunities for health systems, n°4: Republic of Moldova Country Assessment

Like many countries, the Republic of Moldova faces a growing NCD burden. This report examines the challengesand opportunities faced in the Republic of Moldova in order to accelerate improvement in NCD outcomes. Inrecent years, the Government of the Republic of Moldova has implemented a number of important reforms thathave increased effi ciency and equity in resource allocation, and have provided incentives to improve servicedelivery, including for NCDs. Challenges include further scale up and implementation of new initiatives inthe area of NCD risk factor management. Major gains can be made through relatively low-cost public healthand primary health care interventions. These include, among others, strengthening tobacco, alcohol, anddietary polices and their implementation, improving detection and treatment of risk factors for cardiovasculardisease, including hypertension and hyperlipidaemia, strengthening clinical protocols, and improving rationalprescribing practice. This report examines in depth the health system challenges and opportunities for improvedprevention and control of NCDs and concludes with policy recommendations for the consideration of policymakers in the Republic of Moldova.

The updated clinical guideline development process in Estonia is an efficient method for developing evidence-based guidelines.

Clinical practice guidelines are one of the tools available to improve the quality of health care. However, it may be difficult for countries to develop their own national guidelines "from scratch" because of limitations in time, expertise, and financial resources. The Estonian Health Insurance Fund (EHIF), in collaboration with other stakeholders, has launched a national effort to develop and implement evidence-based clinical practice guidelines aimed at improving the quality of care. Although the first EHIF handbook for preparing guidelines was published in 2004, there has been wide variation in the format and quality of guidelines prepared by medical specialty societies, EHIF, and other organizations in Estonia. An additional challenge to guideline development in Estonia is that it is a country with limited human resources. Therefore, revision of the Estonian guideline process was aimed at developing an efficient method for adapting current high-quality guidelines to the Estonian setting without compromising their quality. In 2010, a comprehensive assessment of guideline development in Estonia was made by the World Health Organization, EHIF, the Medical Faculty at the University of Tartu, and selected national and international experts in an effort to streamline and harmonize the principles and processes of guideline development in Estonia. This study summarizes the evaluation of and revisions to the process. Estonia has made substantial changes in its processes of clinical practice guideline development and implementation as part of an overall program aiming for systematic quality improvement in health care. This experience may be relevant to other small or resource-limited countries.

Barriers and facilitators to the implementation of clinical practice guidelines: a cross-sectional survey among physicians in Estonia.

BACKGROUND: In an era when an increasing amount of clinical information is available to health care professionals, the effective implementation of clinical practice guidelines requires the development of strategies to facilitate the use of these guidelines. The objective of this study was to assess attitudes towards clinical practice guidelines, as well as the barriers and facilitators to their use, among Estonian physicians. The study was conducted to inform the revision of the clinical practice guideline development process and can provide inspiration to other countries considering the increasing use of evidence-based medicine. METHODS: We conducted an online survey of physicians to assess resource, system, and attitudinal barriers. We also asked a set of questions related to improving the use of clinical practice guidelines and collected free-text comments. We hypothesized that attitudes concerning guidelines may differ by gender, years of experience and practice setting. The study population consisted of physicians from the database of the Department of Continuing Medical Education of the University of Tartu. Differences between groups were analyzed using the Kruskal-Wallis non-parametric test. RESULTS: 41% (497/1212) of physicians in the database completed the questionnaire, comprising more than 10% of physicians in the country. Most respondents (79%) used treatment guidelines in their daily clinical practice. Lack of time was the barrier identified by the most physicians (42%), followed by lack of medical resources for implementation (32%). The majority of physicians disagreed with the statement that guidelines were not accessible (73%) or too complicated (70%). Physicians practicing in outpatient settings or for more than 25 years were the most likely to experience difficulties in guideline use. 95% of respondents agreed that an easy-to-find online database of guidelines would facilitate use. CONCLUSIONS: Use of updated evidence-based guidelines is a prerequisite for the high-quality management of diseases, and recognizing the factors that affect guideline compliance makes it possible to work towards improving guideline adherence in clinical practice. In our study, physicians with long-term clinical experience and doctors in outpatient settings perceived more barriers, which should be taken into account when planning strategies in improving the use of guidelines. Informed by the results of the survey, leading health authorities are making an effort to develop specially designed interventions to implement clinical practice guidelines, including an easily accessible online database.